SNF QRP Part 2: Falls with Major Injury Quality Measure

This measure, selected by CMS as part of the SNF QRP, will measure the percentage of residents who experience one or more falls, resulting in a major injury, during their SNF Medicare Part A stay.

Before we get into how this measure will be calculated, let’s look at why CMS selected this measure. The Department of Health and Human Services included injury prevention, which incorporates falls prevention, as one of the 10 leading health indicators in the Healthy People 2020 Initiative. In addition, the QRP Measure Specifications cite the following statistics:

  • Falls with injuries represent about 6% of medical expenses among adults aged 65 or older.
  • Fall-related injuries are responsible for approximately 41% of accidental deaths annually.
  • This rate increases to 70% among individuals aged 75 or older.
  • Approximately 75% of nursing facility residents fall at least once a year.
  • It is estimated that 10 – 25% of nursing facility resident falls result in fractures and/or hospitalizations.

Calculating the Falls with Major Injury Quality Measure

As with all QRP Quality Measures, the data used for calculating this QM will come from the MDS. Specifically, data will be derived primarily from MDS item J1900C.

The actual measure will be calculated as follows:

  • Denominator: Number of stays during the reporting period (usually 1 year), with a SNF PPS Part A Discharge Assessment (A0310H = 1). A stay is defined as the period of time from admission/reentry to the facility up to the actual discharge from the Part A stay.
  • Numerator: The number of residents who experienced one or more major falls that resulted in a major injury during the stay.

To determine which residents that will be included in the numerator all scheduled PPS assessments, OBRA Assessments, Discharge Assessments and SNF PPS Part A Discharge Assessment will be reviewed. This is known as the look back scan.

Example: A facility has a total of 250 SNF Part A stays during a 12-month period, this would represent the denominator. Of these stays, there were 10 documented falls with Major Injury in J1900C of one of the eligible assessments in the look back scan.

This would be represented as a fraction as shown here:

10 Falls w/ Major Injury (J1900C)

250 Part A PPS Stays

To express this as a percentage you would divide the numerator by the denominator, and then multiply by 100.

10/250 x 100 = 4%

This would represent the percentage of residents who experienced a fall with Major Injury during this particular reporting period. There are no risk adjustments for this particular measure.

Quality Measure Accuracy

Since all Quality Measure data is derived from the MDS it is of utmost importance that the MDS is coded in accordance with RAI guidance and definitions.

The CMS Survey and Certification Memo (S&C 15-25-NH) has identified J1900C of the MDS as having a high error percentage. As shown here 25 of 94 (25.5%) MDS assessments were found, during the MDS 3.0 Focus surveys, to be coded inaccurately.

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Facility staff responsible for completing Section J of the MDS should review the current definitions related to each type of fall listed in J1900:

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